Preventive Care Coverage in Association Health Plans
Obligations & Requirements
“Preventive care” refers to medical services that are intended to prevent the occurrence of disease or illness. Preventive care ranges from immunizations such as flu shots to tests that detect illness such as a high blood pressure screening. Preventive care also includes forms of health counseling on topics such as proper diet or the prevention of sexually transmitted infections.
There are three groups of preventive services that must be provided by a health plan to plan participants for “free” (i.e. with no out-of-pocket costs). The three groups are:
- Adult preventive care
- Female preventive care
- Pediatric preventive care
Adult Preventive Care
The types of adult preventive care provided with no cost-sharing are:
- An Abdominal aortic aneurysm screening (for men who have ever smoked)
- Alcohol misuse screening & counseling
- Aspirin use for cardiovascular disease & colorectal cancer prevention (for men and women ages 50-59 years who have a high cardiovascular risk)
- Screening for:
- High blood pressure
- High cholesterol
- Colorectal cancer (for men and women ages 50-75)
- Depression
- Hepatitis B (for men and women at high risk)
- Hepatitis C (for men and women at increased risk as well as a single one-time screening for men and women born from 1945 to 1965)
- HIV (for men and women up to age 65 and also for people as young as 15 or for other ages for people at increased risk)
- Lung cancer (for men and women ages 55-80 at high risk)
- Obesity
- Syphilis (for men and women at higher risk)
- Tobacco use
- Tuberculosis (for certain men and women at high risk but without tuberculosis symptoms)
- Type 2 Diabetes (for overweight men and women ages 40-70 years)
- Diet counseling (for men and women at higher risk for chronic disease)
- Falls prevention counseling (for men and women ages 65 years old and up who reside within a community living setting)
- Immunization vaccines
- Diphtheria
- Hepatitis A
- Hepatitis B
- Herpes Zoster
- Human Papillomavirus (HPV)
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pertussis
- Pneumococcal
- Rubella
- Tetanus
- Varicella (Chickenpox)
- Sexually transmitted infection prevention counseling (for men and women at higher risk)
- Statin preventive medication (for men and women ages 40-75 at high risk)
Female Preventive Care
The types of adult female preventive care provided with no cost-sharing are:
- Screenings:
- Anemia
- Breast cancer mammography (annual or semi-annual for women over age 40)
- Cervical cancer
- Chlamydia (for younger women & women at higher risk)
- Diabetes (for women with a history of gestational diabetes who are not pregnant and are not previously diagnosed with type 2 diabetes)
- Domestic & interpersonal violence screening and counseling
- Gestational diabetes (for women who are from 24 to 28 weeks pregnant as well as women who are at a high risk for gestational diabetes)
- Gonorrhea (for women at higher risk)
- Hepatitis B (for pregnant women)
- HIV screening & counseling (for sexually active women)
- Osteoporosis (for women over age 60)
- Preeclampsia screening & prevention (for pregnant women who have high blood pressure)
- Rh incompatibility (for all pregnant women)
- Syphilis (for women at increased risk)
- Tobacco use screening & interventions
- Urinary incontinence
- Urinary tract or other infection
- Additional preventive care services for women include:
- Breast cancer chemoprevention counseling (for women at higher risk)
- Breast cancer genetic test counseling (for women at higher risk)
- Breastfeeding comprehensive support & counseling (for pregnant women and nursing women)
- Contraception (for women with reproductive capacity) – This preventive care is not applicable to health plans sponsored by exempt “religious employers”
- Folic acid supplements for women who may become pregnant
- Sexually transmitted infections counseling (for women who are sexually active)
- Tobacco intervention & counseling (for pregnant women who use tobacco)
- “Well-woman” visits (for women under the age of 65)
Pediatric Preventive Care
The types of child-specific preventive care provided with no cost-sharing are:
- Screenings:
- Autism (for children ages 18 months to 24 months)
- Bilirubin concentration (for newborn children)
- Blood (for newborn children)
- Blood pressure (for various age groups)
- Cervical dysplasia (for girls who are sexually active)
- Depression (for children routinely at age 12)
- Developmental (for children younger than age 3)
- Dyslipidemia (for various age groups)
- Hearing (for various age groups)
- Hematocrit or hemoglobin
- Hemoglobinopathies or sickle cell (for newborn children)
- Hepatitis B (for children at high risk)
- HIV (for children at high risk)
- Hypothyroidism (for newborn children)
- Lead (for children at risk)
- Obesity screening & counseling
- Phenylketonuria (for newborn children)
- Sexually transmitted infection (STI) prevention screening & counseling (for children at higher risk)
- Tuberculin (for various age groups)
- Vision
- Immunizations:
- Diphtheria, Tetanus, Pertussis (Whooping Cough)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus
- Inactivated Poliovirus
- Influenza
- Measles
- Meningococcal
- Pneumococcal
- Rotavirus
- Varicella
- Other preventive care:
- Alcohol, tobacco, and drug use assessments for adolescents
- Behavioral assessments (for various age groups)
- Fluoride chemoprevention supplements for children without fluoride in their water source
- Fluoride varnish (for children as soon as teeth emerge)
- Gonorrhea preventive medication (for newborn children)
- Height, weight, & body mass index measurements (for various age groups)
- Iron supplements (for children ages 6 months to 12 months who are at risk for anemia)
- Medical history (for various age groups)
- Oral health risk assessment (for various age groups)
